Oversees the utilization management activities by evaluating the necessity and efficiency of services through systematic monitoring of medical necessity and quality, while maximizing the appropriate level of care that correlates to the member's benefit plan.
Report to: Sr. Mgr. Prior Authorization
Department: HS-Outpatient Services
Location: Kapolei, HI.
Additional Responsibilities: Candidate Education:
- Reviews and collects medical information in order to determine the medical necessity of services requested by applying specific medical criteria.
- Ensures that services provided to eligible members are within benefit plan and appropriate contracted providers are being utilized.
- Initiates and continues direct communication with health care providers involved with the care of the member to obtain complete and accurate information.
- Identifies appropriate clinical settings for services being requested.
- Identifies and refers cases appropriate for case management.
- Identifies potential quality of care issues and refers to Quality Department.
- Ability to follow and apply all necessary regulatory requirements for assigned market.
- Determines appropriate utilization management of services requested.
- Assists with implementation of healthcare initiatives in market.
- Assists in implementation of specific strategies that improve the quality and outcomes of care.
- Performs other duties as assigned.
- Required A High School or GED
- Required 2 years of experience in Nursing
- Preferred 1 year of experience in Performing utilization reviews
- Preferred Other Experience performing UM in a managed care setting
Licenses and Certifications:
- Intermediate Ability to communicate and make recommendations to upper management
- Intermediate Ability to work independently
- Intermediate Ability to multi-task
- Intermediate Ability to work in a fast paced environment with changing priorities
- Intermediate Demonstrated time management and priority setting skills
- Intermediate Demonstrated written communication skills
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Ability to create, review and interpret treatment plans
- Intermediate Knowledge of healthcare delivery
- Intermediate Ability to effectively present information and respond to questions from families, members, and providers
- Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
- Intermediate Other Strong decision-making and administrative skills
A license in one of the following is required:
- Required Licensed Practical Nurse (LPN)
- Required Beginner Microsoft Excel
- Required Beginner Microsoft Word
- Required Beginner Microsoft Outlook
- Required Beginner Healthcare Management Systems (Generic)